Dr. Smith's ECG Blog

JUNE 11, 2024

Many systems now refrain from showing computer "normal" ECGs to the busy emergency physicians at triage because of very poorly conceived articles that say that if the computer algorithm says "normal," the emergency physician should not be bothered. Three patients with chest pain and “normal” ECGs: which had OMI?

EKG/ECG 111

EKG/ECG Documentation/Coding Emergency Department Wellness 111

Dr. Smith's ECG Blog

JANUARY 27, 2024

Below is the triage ECG, with a computer interpretation (Marquette 12 SL) of “normal” which was confirmed by the over-reading cardiologist. Should this patient continue to stay in the waiting room, without interruption of the physician to interpret the ECG, because the computer interpretation is normal? What do you think?

EKG/ECG 101

EKG/ECG Emergency Department Outcomes Documentation/Coding 101

EMDocs

MAY 4, 2024

. #1: Emergent Cath Lab Activations with “Normal” Computer ECG Interpretations Spoon Feed A significant minority of code STEMI patients have an initial normal computer ECG interpretation. Consequently, emergency physicians must remain vigilant to identify signs of OMI regardless of the initial computer ECG interpretation.

Documentation/Coding 78

Documentation/Coding Stroke Emergency Department Pediatrics 78

PEMBlog

OCTOBER 18, 2024

Duchenne Muscular Dystrophy (DMD) is a complex and progressive disease requiring highly specialized care, especially in emergency situations. When patients with DMD present in the Emergency Department (ED), an understanding of the nuanced aspects of their care is essential for optimal management.

Emergency Department 52

Emergency Department Fractures Best Practices Documentation/Coding 52

EMDocs

SEPTEMBER 26, 2024

EKG, labs, and a CXR are interpreted by the EP as normal. An unknown EP reviews the report, determines that there is no reason to notify the patient, and documents nothing. It wasn’t, so you weren’t called, nor did the doc need to document anything. This patient’s history was either poorly taken or poorly documented.

Radiology 74

Radiology Radiology EKG/ECG Documentation/Coding 74

Dr. Smith's ECG Blog

SEPTEMBER 5, 2023

Here is the ECG: Computer interpretation: Normal ECG Interventionalist after doing PCI: SUBTLE STT CHANGES IN LIMB LEADS To me, this first ECG is diagnostic of inferior OMI. I sent this ECG to the Queen of Hearts (PMcardio OMI), and here is the verdict: YOU TOO CAN HAVE THE PM Cardio AI BOT!! He walked in to triage.

EKG/ECG 83

EKG/ECG Documentation/Coding Emergency Department 83

EMDocs

FEBRUARY 9, 2024

Authors: Adam Roussas, MD, MBA, MSE // Reviewed by: Jamie Santistevan, MD ( @jamie_rae_EMdoc, EM Physician, Presbyterian Hospital, Albuquerque, NM); Manpreet Singh, MD ( @MPrizzleER ); and Brit Long, MD ( @long_brit ) Case A 40-year-old female presents to the emergency department for palpitations and lightheadedness. What do you do?

EKG/ECG 71

EKG/ECG Hyperthermia / Hypothermia EMS Documentation/Coding 71

Don't Forget the Bubbles

JULY 26, 2023

Prioritise listening to the first 30 minutes which given a good overview of aetiology and treatment (53 mins) Basics of cardiac rhythm problems in the ED Palpitations are a common reason for children to present to the emergency department, the majority of these will be benign from a cardiac perspective and instead related to stress or anxiety.

EKG/ECG 98

EKG/ECG Hospitals Shock Documentation/Coding 98

AENJ: Current Issue

SEPTEMBER 30, 2023

The overuse of computed tomographic (CT) scans for patients who present to the emergency department (ED) after mild traumatic brain injury (mTBI) has been well-documented. The Canadian Computed Tomography Head Rule (CCHR) is a validated tool to guide ED providers in determining the need for emergent CT of mTBI patients.

Emergency Department 52

Emergency Department Documentation/Coding Outcomes Wellness 52

EMDocs

SEPTEMBER 23, 2023

Her presenting EKG is shown below. The exact mechanisms by which these genetic mutations lead to the characteristic ECG and arrhythmias seen in Brugada Syndrome are not yet fully understood, but they are thought to involve abnormalities in cardiac ion channels that affect the flow of sodium and calcium ions across cardiac cell membranes 6.

EMS 83

EMS EKG/ECG Documentation/Coding Emergency Department 83

Dr. Smith's ECG Blog

MAY 27, 2024

The ECG did not meet STEMI criteria, and the final cardiology interpretation was “ST and T wave abnormality, consider anterior ischemia”. 1] But there are multiple other abnormalities that make this ECG diagnostic of Occlusion MI, localized likely to the right coronary artery: 1. But are there any other signs of Occlusion MI?

EKG/ECG 118

EKG/ECG Documentation/Coding Emergency Department 118

Dr. Smith's ECG Blog

OCTOBER 2, 2021

Triage EKG: What do you think? A prior ECG was available for comparison. Prior EKG from 2 months ago was available: Let's put the precordial leads from the 2 ECGs side by side: Now you can really see the difference. Immediately after the second ECG was performed, the patient's pain resolved completely.

EKG/ECG 52

EKG/ECG Ultrasounds EMS Documentation/Coding 52

Dr. Smith's ECG Blog

JANUARY 20, 2024

Written by Pendell Meyers A man in his late 30s with history of hypertension, tobacco use, and obesity presented to the Emergency Department for acute chest pain which started approximately 3 hours prior to arrival, in the setting of a very stressful situation. No repeat ECG was done at this time. Repeat ECG shows no changes."

EKG/ECG 114

EKG/ECG Documentation/Coding Emergency Department Hospitals 114

Dr. Smith's ECG Blog

MAY 13, 2024

Written by Destiny Folk, MD, Adam Engberg, MD, and Vitaliy Belyshev MD A man in his early 60s with a past medical history of hypertension, type 2 diabetes, obesity, and hyperlipidemia presented to the emergency department for evaluation of chest pain. See Ken Grauer's additional comments about this ECG at the end of the post!

EKG/ECG 108

EKG/ECG Emergency Department Ultrasounds Documentation/Coding 108

EMDocs

SEPTEMBER 19, 2023

Reference: emDOCs – NCSE Journal of Emergency Medicine – Review Case 4: 52-year-0ld male brought in by EMS with “code STEMI” ECG demonstrates ST depressions with rocket like T waves in V2-V4. This document covers high sensitivity troponin, risk disposition pathways, and STEMI equivalents.

Seizures 72

Seizures Documentation/Coding EKG/ECG Emergency Department 72

Dr. Smith's ECG Blog

APRIL 17, 2023

Sean Rees MD, written by Pendell Meyers, other case by Sam Ghali and Steve Smith Take a look at these two ECGs below from two patients in the ED, first without any clinical context. The remainder of his Emergency Department stay was uneventful. His triage at 0127 is the ECG above. His triage at 0127 is the ECG above.

EKG/ECG 52

EKG/ECG Documentation/Coding Emergency Department Psychiatric 52

Dr. Smith's ECG Blog

JUNE 27, 2024

Smith comment: Go here for a comprehensive blog post on syncope and link to the most detailed version of the Canadian Syncope Rule: Emergency Department Syncope Workup. This is her first ECG in the ED: What do you see? This ECG shows both a right bundle branch block and a posterior fascicular block.

EKG/ECG 117

EKG/ECG Documentation/Coding Emergency Department Wellness 117

Dr. Smith's ECG Blog

AUGUST 9, 2024

Written by Colin Jenkins and Nhu-Nguyen Le with edits by Willy Frick and by Smith A 46-year-old male presented to the emergency department with 2 days of heavy substernal chest pain and nausea. These diagnoses were not found in his medical records nor even a baseline ECG. The patient continued having chest pain.

EKG/ECG 84

EKG/ECG EMS Emergency Department Outcomes 84

ACEP Now

APRIL 4, 2024

A 59-year-old male with a past medical history of a repaired ventricular septal defect (VSD), dextrocardia, hypertension, hyperlipidemia, and current smoker presented to the emergency department (ED). It was immediately discerned that the patient had dextrocardia from previous records, and an EKG for dextrocardia was obtained.

EKG/ECG 40

EKG/ECG Burns Documentation/Coding Emergency Department 40

EB Medicine

MARCH 1, 2019

This month, after a few months of primarily medical topics, we’re talking trauma, specifically Blunt Cardiac Injury: Emergency Department Diagnosis and Management. Post opiate hypotension in prehospital trauma patients is a rare but documented complication. New EKG findings requires admission for monitoring.

Emergency Department 40

Emergency Department EKG/ECG Operations Fractures 40

Dr. Smith's ECG Blog

DECEMBER 27, 2023

Written by Willy Frick A man in his 50s with a history of hypertension, dyslipidemia, type 2 diabetes mellitus, and prior inferior OMI status post DES to his proximal RCA 3 years prior presented to the emergency department at around 3 AM complaining of chest pain onset around 9 PM the evening prior. The following ECG was obtained.

EKG/ECG 116

EKG/ECG Documentation/Coding Wellness Emergency Department 116

Taming the SRU

AUGUST 4, 2024

to teach you and your learner something new on shift skin adhesives WITH dr. hill Dermabond is a polymer (octyl cyanoacrylate) that can be used to repair lacerations in the Emergency Department faster than sutures, allowing the ED physician to be more efficient. It is better to finish early than rushing through your presentation

Emergency Department 85

Emergency Department Dislocations Documentation/Coding Burns 85

Dr. Smith's ECG Blog

DECEMBER 29, 2023

It was ongoing on arrival in the emergency department. Below is the old ECG (on top) and then new ECG (on bottom). The old ECG has proportional ST elevation and T waves. So this STE cannot be considered normal even though there was STE on the previous ECG. But the ECG still doesn’t meet STEMI criteria.

EKG/ECG 70

EKG/ECG Documentation/Coding Emergency Department 70

Dr. Smith's ECG Blog

JANUARY 9, 2024

She presented to the emergency department after a couple of days of chest discomfort. The ECG below was recorded. The ECG was interpreted as showing atrial flutter with 2:1 conduction. Answer : The ECG above shows a regular wide complex tachycardia. How do you interpret the below ECG? This is very prolonged.

EKG/ECG 98

EKG/ECG Stroke Hospitals Documentation/Coding 98

ACEP Now

JUNE 6, 2023

ECG, CXR, and troponin are negative. A medical student reports a murmur, not documented by either the emergency physician or the cardiologist. Troponins #1 and #2 are borderline and ECG is non-specific. In the ED, his troponin, ECG, and chest X-ray (CXR) are normal. ECG, CXR, and troponin are all normal.

EKG/ECG 85

EKG/ECG Stroke Documentation/Coding Operations 85

ACEP Now

JULY 8, 2024

Recently published experiments with LLMs in the emergency department fall into a handful of primary areas of interest. In a similar vein, another study evaluated the ability of an LLM to assess “clinical acuity” in the emergency department. J Am Coll Emerg Physicians Open. 2024;26(1):40-46. JAMA Netw Open.

Emergency Department 52

Emergency Department Operations Documentation/Coding Research 52

Dr. Smith's ECG Blog

DECEMBER 14, 2022

Here are his three EMS ECGs: EMS1 at 0735 This was sent to Dr. Smith with no other information. Meyers sent this ECG to Smith without any other info and this was the response: Smith interpretation: "A very rare anterior OMI w high S-wave voltage." ED ECGs: 0814 0830 These show continued reperfusion with no evidence of reocclusion.

EKG/ECG 52

EKG/ECG EMS Documentation/Coding Emergency Department 52

EB Medicine

JULY 8, 2019

This month, we are sticking in the abdomen for another round of evidence-based medicine, focusing on Emergency Department Management of Patients With Complications of Bariatric Surgery. Vitamin D, B12, Calcium, foate, iron, and thiamine deficiencies are all well documented complications.

Emergency Department 40

Emergency Department Sepsis Operations Dehydration 40

ACEP Now

MARCH 14, 2024

A 44 year-old male with unknown past medical history came by emergency medical services (EMS) to the emergency department (ED) for an electrical injury and fall from a high voltage electrical pole. 1,4-5 Thus, an electrocardiogram (ECG) and cardiac monitoring should be performed for unstable, electrical injury patients.

Burns 52

Burns Fluid Resuscitation EKG/ECG EMS 52

RebelEM

JULY 3, 2023

Impact of intravenous calcium with diltiazem for atrial fibrillation/flutter in the emergency department. Am J Emerg Med. What They Did: Researchers conducted a multicenter, retrospective cohort study in three community hospitals and two freestanding emergency departments. Article: Rossi N et al.

Administration 98

Administration Outcomes Documentation/Coding Emergency Department 98

RebelEM

MARCH 9, 2023

However, evaluating and managing patients with acute alcohol intoxication in the emergency department can be challenging. Document at each reassessment and always have a low threshold to add on a CTH or labs if the patient is not progressing appropriately. As always, document clinical sobriety before discharge.

Psychiatric 52

Psychiatric Emergency Department Documentation/Coding Fractures 52

Dr. Smith's ECG Blog

NOVEMBER 12, 2020

He had the following EKG recorded: Low voltage, suggests effusion. A Rising Troponin That afternoon, he complained of increased shortness of breath and was noted to have oxygen saturations in the 70s, prompting a mini code to be called. This is the ECG on V-V ECMO: Very little STE He had a lot of troponins measured.

Shock 52

Shock EKG/ECG Outcomes Hospitals 52

Dr. Smith's ECG Blog

DECEMBER 14, 2018

The pain resolved as he arrived to the emergency department. Here was his triage ECG. This appears to be a classic Wellens' ECG, Pattern A, with terminal T-wave inversion in V2-V4, preserved R-waves, and it appears to be Wellens' syndrome, as it occurred after resolution of typical angina pain. BP was 200/100.

EKG/ECG 52

EKG/ECG Documentation/Coding Emergency Department Wellness 52

Dr. Smith's ECG Blog

NOVEMBER 28, 2022

Written by Destiny Folk MD, with edits by Meyers, peer reviewed by Smith and Grauer A woman in her late 20s with a past medical history of cervical cancer status post chemotherapy and radiation therapy presented to the emergency department for shortness of breath, chest tightness, and two episodes of syncope.

EKG/ECG 52

EKG/ECG Ultrasounds Documentation/Coding COPD 52

ACEP Now

JULY 6, 2023

Emergency physicians have earned the right to “re-brand” ourselves as indispensable, money-saving change agents in the health care enterprise. Of course, the bill for any episode of emergency department (ED) care can be substantial, exceeding the billed charges for equivalent care provided in some primary care offices.

Head Injuries 52

Head Injuries Emergency Department Research Pediatrics 52

Dr. Smith's ECG Blog

DECEMBER 27, 2018

This ECG comes from Pierre Taboulet ( [link] /)( [link] ) an ECG whiz who codes a lot of ECGs for Cardiologs' Artificial Intelligence Deep Neural Network algorithm ( [link] ). A Deep Neural Network learning algorithm outperforms a conventional algorithm for emergency department electrocardiogram interpretation.

EKG/ECG 52

EKG/ECG Documentation/Coding Emergency Department Wellness 52

Dr. Smith's ECG Blog

NOVEMBER 26, 2015

52-year-old lady presents to the Emergency Department with 2 hours of chest pain, palpitations & SOB. Here is her 12-Lead ECG: There’s a sinus rhythm at around 70 bpm. It is difficult to answer this question based on this single ECG alone. This was written by Sam Ghali ( @ EM_RESUS ), with a few edits by me.

EKG/ECG 52

EKG/ECG Wellness Documentation/Coding Emergency Department 52